Efficacy of short-term versus long-term chest tube drainage following talc slurry pleurodesis in patients with malignant pleural effusions: A randomised trial
Introduction
Malignant pleural effusions are a common cause of morbidity and admission to hospital. The majority of small malignant effusions will progress and increase in size if not treated and although therapeutic aspiration of fluid or insertion of a chest drain is associated with rapid relief from breathlessness, recurrence rates may be up to 100% after 1 month [1]. Repeated drainage increases the likelihood of fluid forming locules and trapping of the lung preventing re-expansion. The British Thoracic Society therefore recommends early pleurodesis for patients with malignant effusions who are symptomatic with breathlessness from their pleural fluid and have improvement in symptoms with thoracocentesis [1].
Pleurodesis can be performed by ‘medical’ pleurodesis, where an agent is instilled into a chest drain, or by surgery such as video assisted thoracoscopic surgery (VATS). A number of chemical agents have been used to perform medical pleurodesis including bleomycin; tetracycline; doxycycline; Corynebacterium parvum and sterile talc. Sterile talc is currently recommended in the BTS guidelines with success rates averaging 90% (range 88–100%) [1]. Medical pleurodesis is usually performed on in-patients via insertion of an intercostal chest drain and instillation of talc as slurry. Adequate preparation of the pleural space is vital to the success of pleurodesis as residual fluid will reduce the efficacy, but it is not clear how long the drain needs to remain after instillation of talc. As patients with terminal disease and only short expected survival are anxious to avoid long periods of hospitalisation, reducing the length of hospital stay whilst still achieving successful pleurodesis is likely to be of benefit. A previous trial using tetracycline pleurodesis, found that removal of the chest drain after 24 h was as effective as standard protocol drain removal (once drainage less than 150 ml/day) leading to a reduction in hospital stay [2]. No studies have assessed drain removal after talc slurry pleurodesis. This study investigates whether talc is effective in pleurodesis if the drain is removed at 24 h versus 72 h after chemical instillation.
Section snippets
Subjects
All patients studied had confirmed malignant pleural effusion requiring palliation of breathlessness due to this effusion. Patients were excluded if: (1) expected survival was less than 3 months; (2) Karnofsky score was less than or equal to 40 (disabled, requires special care and assistance); (3) had undergone a previous unsuccessful pleurodesis; (4) had ipsilateral endobronchial obstruction; or (5) evidence of ‘trapped lung’ following drainage of pleural fluid. Trapped lung was defined as
Subjects
Forty-one patients were recruited to this study from January 2001 to July 2004 (Fig. 1). The baseline characteristics of the groups (age, sex, cell type, duration of stay before procedure) were comparable between the two groups (Table 1). The study was terminated at the planned end-point.
Length of stay
The median length of hospital stay (Table 2, Fig. 2) was significantly shorter for those who had a drain in situ for 24 h versus 72 h (4 days (interquartile range 4–8) versus 8 days (interquartile range 6–9); p <
Discussion
This study has shown that the instillation of talc slurry to perform medical pleurodesis for the management of malignant pleural effusions remains effective when the drain is removed at 24 h rather than 72 h after chemical instillation. This leads to a shorter period of hospitalisation for patients who already have minimal life expectancy, with obvious benefits to patients and cost savings for the healthcare system.
There is widespread variation in the methods clinicians use to perform medical
Conflicts of interest
No conflicts of interest for either author relating to this study.
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